Alexandre Forster

Pain intensity and pain relief after surgery. A comparison between patients' reported assessments and nurses' and physicians' observations.

Background: Postoperative pain remains a problem for many patients. One of the reasons could lie in the insufficient evaluation of pain and analgesia. This study was designed to obtain more insight in the performance of nurses and physicians in evaluating patients’ postoperative pain and pain relief.

The influence of an aging surgical population on the anesthesia workload: a ten-year survey

To assess the evolution of the anesthetic workload related to elderly population (>or=to65 yr) at the University Hospital of Geneva, the total number of anesthesia cases, high-risk patients, and emergency procedures, as well as the total duration of anesthesia and incidence of perianesthetic complications, were retrospectively analyzed over 10 yr. The squared correlation coefficient was used to assess the proportion of variance explained by the linear regression of the absolute and the relative number of events over time. More than 165,000 anesthesia procedures were analyzed, and the data were separated into two groups: the younger population (<65 yr) and the elderly population (>or=to65 yr). From 1985 to 1994, the elderly surgical population grew significantly faster (P < 0.001) than the elderly resident population (from 20.3% to 25.1% versus from 12.5% to 13.6%). Half of the increased number of anesthesia cases during this period were administered to elderly patients. The number of high-risk elderly patients increased by 48.3% (P < 0.0001). The number of emergency procedures in elderly patients increased only until 1991, and a significant decrease in the incidence of perianesthetic complications was observed. Because the mean duration of each procedure remained constant, the increased anesthetic workload in our institution was mainly due to increased geriatric surgical activity. Implications: During a study period of 10 yr, the increased anesthetic workload (defined as the number of anesthesia cases, high-risk patients, emergency procedures, and complication rate) at the University Hospital of Geneva was mainly due to the increased geriatric (patients >or=to65 yr) surgical activity, not to the aging of the resident population. (Anesth Analg 1998;86:1165-70)

A Rare Case of Adrenal Insufficiency Induced by Inhaled Corticosteroids

1. Christensen PB, Jensen TS, Tsiropoulous I et al. Incidence and prevalence of myasthenia gravis in western Denmark: 1975–1989. Neurology 1993;43:1779–1783. 2. Phillips LH, Torner JC. Epidemiology evidence for a changing natural history of myasthenia gravis. Neurology 1996;47:1233–1238. 3. Schon F, Drayson M, Thompson RA. Myasthenia gravis and elderly people. Age Aging 1996;25:56–58. 4. Aragon es JM, Bol ıbar I, Bonfill X et al. Myasthenia gravis: A higher than expected incidence in the elderly. Neurology 2003;60:1024–1026. 5. Vincent A, Clover L, Buckley C et al. UK Myasthenia Gravis Survey. Evidence of underdiagnosis of myasthenia gravis in older people. J Neurol Neurosurg Psychiatry 2003;74:1105–1108. 6. Lawrence H, Phillips LH. The epidemiology of myasthenia gravis. Semin Neurol 2004;1:17–20. 7. Matsui N, Nakane S, Nakagawa Y et al. Increasing incidence of elderly onset patients with myasthenia gravis in a local area of Japan. J Neurol Neurosurg Psychiatry 2009;80:1168–1171.

Comparison of the interobserver variability of 2 different methods of dietary assessment in a geriatric ward: a pilot study

BACKGROUND Protein-energy malnutrition is highly prevalent in aged populations. Associated clinical, economic, and social burden is important. A valid screening method that would be robust and precise, but also easy, simple, and rapid to apply, is essential for adequate therapeutic management. OBJECTIVES To compare the interobserver variability of 2 methods measuring food intake: semiquantitative visual estimations made by nurses versus calorie measurements performed by dieticians on the basis of standardized color digital photographs of servings before and after consumption. DESIGN Observational monocentric pilot study. SETTING/PARTICIPANTS A geriatric ward. The meals were randomly chosen from the meal tray. The choice was anonymous with respect to the patients who consumed them. MEASUREMENTS The test method consisted of the estimation of calorie consumption by dieticians on the basis of standardized color digital photographs of servings before and after consumption. The reference method was based on direct visual estimations of the meals by nurses. Food intake was expressed in the form of a percentage of the serving consumed and calorie intake was then calculated by a dietician based on these percentages. The methods were applied with no previous training of the observers. Analysis of variance was performed to compare their interobserver variability. RESULTS Of 15 meals consumed and initially examined, 6 were assessed with each method. Servings not consumed at all (0% consumption) or entirely consumed by the patient (100% consumption) were not included in the analysis so as to avoid systematic error. The digital photography method showed higher interobserver variability in calorie intake estimations. The difference between the compared methods was statistically significant (P < .03). CONCLUSIONS Calorie intake measures for geriatric patients are more concordant when estimated in a semiquantitative way. Digital photography for food intake estimation without previous specific training of dieticians should not be considered as a reference method in geriatric settings, as it shows no advantages in terms of interobserver variability.

Giant Mucinous Ovarian Tumor

CLINICAL PRESENTATION A n 87-year-old female patient was admitted to a geriatric ward after a fall. She reported worsening abdominal discomfort and urge urinary incontinence for several months. On admission, physical examination revealed abdominal distention with slight diffuse tenderness and dilated superficial collateral veins (Figure 1). Suprapubic percussion showed an abnormally vast dull pitch, extending over the umbilicus. Abdominal computed tomography confirmed a large heterogeneous cystic abdominal mass measuring 24.5 3 19.5 3 16.5 cm, with multiple septa mostly at its upper portion (Figure 1B). An ultrasound-guided biopsy demonstrated a mucinous ovarian tumor. The patient underwent abdominal surgery with tumorectomy, bilateral adnexectomy and hysterectomy. A 26 cm 3 22 cm 3 14 cm mass weighing 3900 g was excised (Figure 1C). Histological samples confirmed a borderline, intestinal-type, mucinous tumor of the left ovary (Figure 1D) with foci of intraepithelial carcinoma, confined to the ovary. On follow-up, urinary incontinence disappeared. Ovarian tumors present frequently with nonspecific symptoms. Diagnosis may be even harder in elderly patients where clinical presentations tend to be atypical. Frequent geriatric syndromes such as urinary incontinence also tend to be overlooked as simply “age related” and often remain without adequate care. Abdominal imaging should be more readily performed in elderly patients with urinary symptoms to provide adequate diagnosis and treatment.

Quantitative Evaluation of Tourniquet Leak During I.V. Regional Anaesthesia of the Upper and Lower Limbs in Human Volunteers

Although it is accepted that during i.v. regional anaesthesia (IVRA) local anaesthetic can leak under the tourniquet into the systemic circulation, no published study has evaluated this leak quantitatively. In volunteers, during two random sessions, we have simulated IVRA using standard techniques with a radiolabelled compound which is chemically similar to lignocaine and has comparable tissue distribution (0.1 mg of HIDA labelled with 100 muCi of 99mTc in 40 ml of saline). The decrease in radioactivity was measured with a gamma camera for the 20 min of tourniquet inflation and for the 20 min of washout after cuff deflation. While the tourniquet was inflated, the leak for the lower limb (mean 29 (SD 8) %) was significantly greater (P < 0.004) than the leak for the upper limb (15 (5) %). Moreover, in each of 10 volunteers, the leak was always greater for the lower than the upper limb. During the first 3 min after tourniquet deflation the loss of radioactivity was 58 (8) % of the maximal amount for the upper limb and 39 (8) % for the lower limb (P < 0.001). As the leak under the tourniquet was significantly greater for the lower than the upper limb, we conclude that IVRA for the lower limb can be associated more frequently with a shorter duration of successful anaesthesia and/or failure.

Comparison of hyperbaric solutions of buplvacaïne and tetracaïne during continuous spinal anesthesia

The aim of this study was to compare two equipotent solutions of hyperbaric bupivacaine and tetracaine in 30 elderly patients undergoing elective hip surgery under continuous spinal anaesthesia. With the patient in the supine position, 2 ml (8 mg) of either hyperbaric solution (density 1.030) were administered in a double-blind and randomized fashion. The median maximum sensory and temperature discrimination levels (T5 and T4) were similar with both solutions. The duration of analgesia was not different (114 +/- 23 min for bupivacaine and 125 +/- 35 min for tetracaine). Thirteen out of fifteen patients receiving bupivacaine and all 15 patients receiving tetracaine had complete motor blockade. The haemodynamic changes and vasopressor requirements were comparable. The plasma catecholamine levels measured at four different times remained unchanged and were not different between the two groups at any time. The authors conclude that, during continuous spinal anaesthesia, equipotent hyperbaric solutions of bupivacaine and tetracaine have similar anaesthetic and haemodynamic effects.